Radiology

Consultant radiologist Brian Kelly explains that there is a bit more to radiology than holding x ray films up to the light

You may think the role of radiologists is only to creep about in the basements of hospitals doing tests on the unsuspecting, and picking out medical students at clinical meetings for their own malicious pleasure. This, of course, is tremendous fun, but the question remains: how did we get to be this way? Surely we would be better off if we merely told the radiographers to hand the films over directly to the clinicians. That way they could hold the films up to the nearest light and murmur, "Hmmm, looks a bit patchy and fluffy round there." However, radiologists have undergone intensive training, so let us pontificate for a while. After that, you can "borrow" the films for the ward round, hold them up to the light, and discuss what you think the problem really is!

What is a radiologist?
Radiologists are diagnosticians who use various imaging modalities to reach their conclusions. Originally these modalities all involved the use of ionising radiation, but since the advent of ultrasound and magnetic resonance imaging (MRI) this is no longer the case. In addition, the evolution of interventional radiology and the continued improvements in imaging resolution has led to increased therapeutic possibilities.

Imaging now impacts on almost all medical specialties, from general practice, through medicine, surgery, obstetrics, and orthopaedics to psychiatry. Referral from the general practitioner to specialist, and the subsequent algorithm, can depend on the availability of imaging facilities. Currently there are two main types of radiologists.

Body imagers
These are shy herbivorous creatures who surround themselves with celluloid. Type B personality, usually. Speak in clipped, dictating, sentences, liberally punctuated.

Interventional radiologists
Type A personalities. Speak exclusively in cryptic crossword clues; "tracked into the A2 with a microferret" sort of thing.

Yes, but what exactly do radiologists do?
Good question. Obviously, there are differences between those who might work in a tertiary referral centre with a particular specialist interest, and others who work in a district general hospital. Typically, however, a working week would involve barium work, cross-sectional imaging such as computed tomography (CT), MRI and ultrasound, nuclear medicine, intervention and, of course, plain film reporting. Therein lies part of the attraction of this career. There is an enormous breadth of medicine to be experienced in the typical working day, and it is, for example, routine to consider differential diagnoses in subjects as diverse as cardiology, thoracic surgery, oncology, neurology, orthopaedics, accident and emergency, and general medicine in a single CT list.

There isn't much patient contact though, is there?
It is true that we do not have as much clinical follow up as other specialties, although this is changing, particularly in the interventional subspecialty. We do, however, except in MRI and CT, spend the day in close proximity to our patients, particularly when performing ultrasound. As you watch the monitor, the patient watches you, looking intently for any verbal or non-verbal clue as to the nature of their condition. It is salutary to remember that the majority of our patients are nervous, if not actually frightened of what our tests may reveal. It is therefore very helpful to be able to try to reduce a patient's anxiety during an examination, and hopefully reassure them at the end of it.

How do I get in then?
Trainees should have two years of clinical experience, at least one at postregistration level. Many of the training schemes insist on part 1 of the MRCP, MRCS, MRCOG or equivalent, and it is not uncommon for training programmes to attract applicants with complete higher qualifications. It is worth seeking local advice from specialist registrars or the training director of the local training programme.

How does the training work?
There is a very structured training in clinical radiology for specialist registrars, with emphasis on consultant led departments. This can be somewhat disconcerting for some new trainees, who may previously have enjoyed considerable autonomy, as they find themselves and their work heavily supervised.

Structured training in clinical radiology is undertaken over a period of five years. This training broadly breaks down as follows:

Year 1
Skills in radiological techniques, anatomy, and physics are acquired in this period. Although changes to the first part curriculum are likely in the near future, there are no plans to remove the physics teaching from the syllabus.

Years 2 to 4
There are 36 months of structured training to cover the subspecialties in the core curriculum and the core experience. This can be considered as system based subspecialties, such as vascular, cardiac, chest, musculoskeletal and neuroradiological imaging; technique based subspecialties, such as CT, ultrasound, MRI, and intervention; disease based subspecialties, such as oncology and trauma; and age based subspecialties, such as paediatrics.

Year 5
A 12 month period of higher professional training, which allows concentrated training in one (or more) subspecialties. This can be taken in a modular form within the fourth and the fifth year. An additional year (year 6) is required for training in particular subspecialties such as neuroradiology, interventional radiology, and nuclear medicine.

Examination structure
There are currently two examinations, the first and final Fellow of the Royal College of Radiologists (FRCR) examinations. At present the first FRCR examination deals with radiological techniques, physics, and anatomy (though it is likely that in the near future this examination may cover less). Typically, candidates sit this examination in the summer of their first year, although a significant proportion have to resit it in the following autumn.

The final FRCR examination is in two parts. Part A is an MCQ examination and part B focuses on viva and reporting skills. This examination is very challenging, and is considered one of the most difficult of the postgraduate examinations.

And finally...
So there you have it. If the idea of variety, the occasional spot of detective work, interventional procedures, and using high tech equipment appeals, this may well be the career for you. Medical student electives are often available at your local friendly radiology department if you fancy dipping your toe into the water. A few weeks spent absorbing the mysteries of chest radiology, for example, might make you a wiser and safer doctor. Of course, you could just hold the films up to the light.